Fill and Sign the Adoption Petition Vermont Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) ADOPTION PETITION 15A V.S.A. § 3-404 Part I. The undersigned petitioner(s) represent that: 1. The person to be adopted is: Name: __________________ , Place of birth: __________________ Date of birth: __________________ , Time of birth: ________ Sex: male , To be known as: ___________________ Child has resided with petitioner(s) since: ___________________ Child is an Indian child as defined by Indian Child Welfare Act. 2. The petitioner(s) are: Name: ____________________________________________ , Date of birth: __________________ Mailing address: ____________________________________________ ____________________________________________ Town and state of residence: ____________________________________________ For how long? ____________________________________________ Occupation: ____________________________________________ , Approximate in-come: ___________________________________ Current marital status: _____________________________ , Is divorce pending? yes - 1 - If married, has spouse been judicially determined to be incompetent? ___________________________________ ________________________________________________ Relationship to adoptee: ________________________________________________ Date of most recent favorable preplacement evaluation: ________________________________________________ Date, court and disposition of any previous petition to adopt: ________________________________________________ ________________________________________________ ________________________________________________ Name: ____________________________________________ , Date of birth: __________________ Mailing address: ____________________________________________ ____________________________________________ Town and state of residence: ____________________________________________ For how long? ____________________________________________ Occupation: ____________________________________________ , Approximate in-come: ___________________________________ Current marital status: _____________________________ , Is divorce pending? yes If married, has spouse been judicially determined to be incompetent? ___________________________________ ________________________________________________ Relationship to adoptee: ________________________________________________ Date of most recent favorable preplacement evaluation: ________________________________________________ Date, court and disposition of any previous petition to adopt: ________________________________________________ ________________________________________________ ________________________________________________ 3. The petitioners acquired physical custody of the minor on: Date If the child is not in the physical custody of the petitioners, explain the reason and the date and manner in which the petitioners intend to obtain physical custody: ______________________________________________________ ______________________________________________________ - 2 - 4. If the child was born out of wedlock, have the parents intermarried? yes If the child's parents are divorced, custody was awarded to ______________________________________________________ 5. The name and address of the person or agency who placed the child with the petitioners is: ______________________________________________________ ______________________________________________________ ______________________________________________________ If not an agency, the relationship of the person who placed the child with the petitioners is: ______________________________________________________ 6. The description and approximate value of known property of the minor is: ______________________________________________________ ______________________________________________________ 7. The petitioner is aware that the following court orders are in effect or pending regarding the child: Child support: ______________________________________________________ Custody: ______________________________________________________ Visitation or contact: ______________________________________________________ 8. The petitioner(s) have completed the list of interested persons in Part I and have attached or explained in an attached affidavit the absence of the documents listed in Part III. 9. Any law governing interstate or intercountry adoption was complied with, if applicable. 10. The petitioners have the facilities and resources to provide for the care and support of the child and request that they be permitted to adopt the child. In addition, the following relief is sought: ___________________________________________ ______________________________________________________ ______________________________________________________ - 3 - Part II. Persons Interested in Adoption Proceeding The undersigned petitioner(s) represents that the following is a list of persons interested in the adoption of the above-named child as far as is known to me: 1. Mother's name: ______________________________________________________ Mailing address: ______________________________________________________ ______________________________________________________ Town of residence: ______________________________________________________ 2. Name of husband of the mother, if the child was born during the marriage or within 300 days after its termination: Mailing address: ______________________________________________________ Town of residence: ______________________________________________________ 3. Name of biological father identified by the mother: Mailing address: ______________________________________________________ ______________________________________________________ Town of residence: ______________________________________________________ 4. Name of any other man who was not married to the mother at the time of the child's birth, has acknowledged paternity and has demonstrated a parenting relationship with the child, including financial: _______________________________________ Mailing address: ______________________________________________________ ______________________________________________________ Town of residence: ______________________________________________________ 5. Name of the child's legal guardian: ______________________________________________________ Mailing address: ______________________________________________________ ______________________________________________________ - 4 - Town of residence: ______________________________________________________ Part III. The following documents are attached to the petition: A. Originals or certified copies of: Child's birth certificate or other record of date and place of birth: Any consent, relinquishment, order terminating parental rights or disclaimer of parental interest that have been executed; Written certification required of person before whom the consent or relinquishment was executed; Each parent or former parent's marriage certificate, decree of divorce, annulment or dissolution, or agreement of legal separation; Any court order determining the former parent's incompetence; Any existing court order or petition in a pending proceeding concerning custody of, or visitation or communication with, the child; Petitioner's marriage certificate, decree of divorce, annulment or agreement of legal separation; Any court order determining that the spouse of the petitioner is incompetent. B. Copies of: Replacement evaluation on the petitioner(s); Post placement evaluation; Report on the child and family's background information required by § 2-105; Any agreement with a public agency for adoption subsidy; Any collateral agreement between the petitioner and parent or guardian or any agency; - 5 - Any request for nondisclosure signed by the parent or former parent. C. If an agency placed the child for adoption, a verified statement from the agency is required by § 3-305(a)(10). Part IV. Affidavit of Unavailable Information: I, _______________________ , after first being sworn, state that I am unable to provide the following information in Parts I, II or III: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ because the information is not known to me or not available to me after reasonable attempts to get it. Dated at __________ , this ____ day of ____________ , 20 ____ . __________________________________________ , Petitioner __________________________________________ , Petitioner Subscribed and sworn to this _____ day of __________ , 20 ___ before me, ______________________________________________ , Notary Public Subscribed and sworn to this _____ day of __________ , 20 ___ before me, _____________________________________________ , Notary Public Note: This form must be filed in duplicate Rev.3/1/97 - 6 -